British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, BC, Canada.
Centre for Health Evaluation & Outcome Sciences, Vancouver, BC, Canada.
J Subst Abuse Treat. 2022 Aug;139:108784. doi: 10.1016/j.jsat.2022.108784. Epub 2022 Apr 29.
People who use unregulated drugs (PWUD) often face significant barriers to-and thereby avoid seeking-health care. In Vancouver, Canada, a neighborhood-wide health care system reform began in 2016 to improve health care delivery and quality. In the wake of this reform, we sought to determine the prevalence of health care avoidance and its association with emergency department use among PWUD in this setting and examine patient-reported nonmedical qualities of health care ("responsiveness").
The study derived data from two prospective cohort studies of community-recruited PWUD in Vancouver in 2017-18. Responsiveness was ascertained by the World Health Organizations' standardized measurements and we evaluated seven domains of responsiveness (dignity, autonomy, communication, confidentiality, prompt attention, choice of provider, and quality of basic amenities). The study used Pearson chi-squared test to examine differences in responsiveness between those who did and did not avoid care. The study team used multivariable logistic regression to determine the relationship between care avoidance due to past mistreatment and emergency department use, adjusting for potential confounders.
Among 889 participants, 520 (58.5%) were male, 204 (22.9%) reported avoiding health care, most commonly for chronic pain (47.4%). Overall, 6.6% to 36.2% reported suboptimal levels (i.e., not always meeting the expected quality) across all seven measured domain of responsiveness. Proportions reporting suboptimal qualities were significantly higher among those who avoided care than those who did not across all domains, including care as soon as wanted (51.0% vs. 31.8%), listened to carefully (44.1% vs. 20.4%), and involved in health care decision-making (27.9% vs. 12.7%) (all p < 0.05). In multivariable analyses, avoidance of health care was independently associated with self-reported emergency department use (adjusted odds ratio = 1.49; 95% confidence interval:1.01-2.19).
We found that almost a quarter of our sample of PWUD avoided seeking health care due to past mistreatment, and all seven measured domains of responsiveness were suboptimal and linked with avoidance. Individuals who reported avoidance of health care were significantly more likely to report emergency department use. Multi-level interventions are needed to remedy the suboptimal qualities of health care and thereby reduce care avoidance.
使用未经管制药物的人（PWUD）在寻求医疗保健方面常常面临重大障碍。在加拿大温哥华，2016 年开始进行了一项全社区范围的医疗保健系统改革，以改善医疗保健的提供和质量。在这项改革之后，我们试图确定在此环境中 PWUD 回避医疗保健的流行程度及其与急诊部门使用之间的关联，并检查患者报告的非医疗保健质量（“响应性”）。
本研究从 2017-18 年在温哥华社区招募的社区 PWUD 的两项前瞻性队列研究中获取数据。通过世界卫生组织的标准化测量来确定响应性，我们评估了响应性的七个领域（尊严、自主、沟通、保密性、及时关注、提供者选择和基本设施质量）。研究使用 Pearson 卡方检验来检查在回避和不回避医疗保健的人群之间，在响应性方面的差异。研究小组使用多变量逻辑回归来确定由于过去受到虐待而回避护理与急诊部门使用之间的关系，同时调整了潜在的混杂因素。
在 889 名参与者中，520 名（58.5％）为男性，204 名（22.9％）报告回避医疗保健，最常见的原因是慢性疼痛（47.4％）。总体而言，在所有七个测量的响应性领域中，有 6.6％至 36.2％的人报告了次优水平（即，并未始终达到预期的质量）。在所有领域中，与未回避医疗保健的人群相比，回避医疗保健的人群报告次优质量的比例明显更高，包括尽快获得护理（51.0％比 31.8％）、仔细倾听（44.1％比 20.4％）和参与医疗保健决策（27.9％比 12.7％）（所有 p <0.05）。在多变量分析中，回避医疗保健与自我报告的急诊部门使用独立相关（调整后的优势比=1.49；95％置信区间：1.01-2.19）。
我们发现，我们的 PWUD 样本中有近四分之一因过去受到虐待而回避寻求医疗保健，所有七个测量的响应性领域的质量均不理想，并与回避相关。报告回避医疗保健的人更有可能报告急诊部门的使用。需要采取多层次的干预措施来改善医疗保健的次优质量，从而减少回避行为。
